Claim Form

1. ABOUT YOU

a) Full name

b) Address:

Postcode:

Telephone: Daytime:

evening:

Fax:

E-mail:

c) Occupation:

d) Date of birth:

e) ODYSSEY Policy No:

2. ABOUT THE RENTAL VEHICLE

a) Vehicle Registration:

b) Make & Model:

c) Rental Company Name:

d) Location of Rental:

e) Period of Rental:

3. ABOUT THE INCIDENT

a) Details of the driver (if not you):
Name:

Address:

Post Code:

Date of Birth:

Type of Licence held (Provisional/Full):
If not Full please advise restrictions

Date passed test:

b) Time and date of incident

c) Where did the incident occur?

d) Details of Incident

e) Nature of damage

f) Was a third party involved?
Yes – Please complete Section 4. below
No – Please go to Section 5.

Yes No

4. ABOUT THE THIRD PARTY

a) Full name of Driver

b) Address of Driver

Post Code

Telephone No

Email address

c) Name and address of Third Party’s Insurance Company

Telephone No

d) Policy No

e) Who was at fault?

f) Details of damage to Third Party

g) Details of Third Party’s injuries

5. POLICE/LAW ENFORCEMENT

a) Was the incident reported to the police/local law enforcement agency?

b) Name of officer

c) Police/law enforcement office address

d) Incident/Crime reference number

6. DETAILS OF WITNESSES

a) Names and Addresses

7. OTHER INSURANCES

a) Have you previously been insured for losses of this nature?

If so, please provide particulars

b) Do you hold any other insurance policies which cover this incident?

8. AMOUNT BEING CLAIMED

a) Amount you are being held responsible for by the Vehicle Rental Outlet
Please attach copy letter or invoice

c) Have you paid the Vehicle Rental Outlet?
If so, please advise amount, date and method of payment. Was this payment in full settlement of the amount the Vehicle Rental Outlet is holding you responsible for?

9. DECLARATION
I hereby declare the particulars and statements to be true in every respect and that I have withheld no information relative to the occurrence or claim and my permission is given to the Insurers to contact any other party mentioned on this form.

Please, type down secure code :

Download Claim Form in PDF
Fill in and sign the document and sent it back by fax, postal service or scanned by e-mail

Isle of Man Assurance Limited underwrite the Odyssey range of insurance policies under licence from Odyssey Group Limited.
For the purposes of the Terms and Conditions "We", "Our" and "Us" refers to Odyssey Group Limited and Isle of Man Assurance Limited for their respective rights and interests.
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